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A nurse-centered primary health care model for HIV care of patients with active tuberculosis: antiretroviral treatment initiation decision making
A. Van Rie1, N. Mbonze2, K. Tillerson1, F. Kitenge3, I. Roger1, K. Vanden Driessche2, F. Behets1
1University of North Carolina, Epidemiology, Chapel Hill, United States, 2UNC-DRC, Kinshasa, Congo, the Democratic Republic of the, 3University of Kinshasa, School of Public Health, Kinshasa, Congo, the Democratic Republic of the
Background: Tuberculosis (TB) is the most common AIDS presenting illness and frequent cause of death in people living with HIV. Integration of HIV and TB care is therefore imperative. While TB care is decentralized and nurse-focussed, most antiretroviral treatment (ART) clinics are centralized and physician-based. Task shifting for integrated TB/HIV care could facilitate ART access for TB patients. We initiated and evaluated a comprehensive HIV care and treatment program implemented by nurses at primary health care clinics, and compared nurses' decision making to that of physicians.
Methods: ART eligibility algorithms and regimen selection tools were developed. TB nurses were trained in HIV care, including clinical staging, opportunistic infections, and basics of ART. HIV co-infected TB patients were recruited at 5 clinics in Kinshasa, DRC. ART initiation decisions were made by nurses and ART-certified physicians on the same day, each blinded to the other's decision. Physicians visited the clinics once a week and were available by phone for advice.
Results: Among 229 TB patients, 185 (80.8%) were ART eligible, 44 (23.8%) according to clinical staging (extrapulmonary TB or other stage IV) and 141 (76.2%) because of CD4 count below 350. ART initiation decisions and regimen selections by nurses and physicians were available for 171 (95%) and 168 (93.3%) patients, respectively. Agreement on ART initiation was 94.7%. Physicians disagreed with the nurse's decision to start in 9 cases, mainly because of the presence of other opportunistic infections. Agreement on ART regimen was 92.9%. Physicians preferred AZT to d4T in 8 patients, and NVP to EFZ in 4 patients.
Conclusions: In this ongoing evaluation, nurses' decision making was comparable to that of certified physicians. A nurse-centered, primary health care based ART program for patients with TB in a resource-limited setting could be an effective model for scale-up of HIV services for TB patients.
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